Bulletin on Narcotics
Volume LI, Nos. 1 and 2, 1999
Substance abuse among secondary-school students and its relationship with social coping and temperament
G. GERRA, A. ZAIMOVIC, O. RIZZI, M. TIMPANO
AND U. ZAMBELLI
Drug Addiction Research Center, Servizio Tossicodipendenze, Azienda Unità Sanitaria Locale di Parma, Italy
Institute of Sociology, University of Parma, Italy
Material and methods
Questionnaire on substance abuse
Questionnaire on behavioural, social and environmental factors
Alcohol, cannabis and ecstasy use was investigated in a representative sample of 843 secondary-school students aged 14-19. In addition to answering questions on substance use, the participants completed questionnaires concerning social and behavioural factors, achievement at school and perceived substance use among friends. All the students completed Cloniger's Tridimensional Personality Questionnaire and the Eysenck questionnaire. It was found that 76.5 per cent of the students had consumed alcohol at least once in their lives, 38.4 per cent had abused alcohol, 27.1 per cent had used cannabis and 5.5 per cent had used ecstasy. Gender differences were significant in the use of alcohol and ecstasy, with male subjects outnumbering females; the trend was reversed for cannabis use. The extent of exposure to alcohol and illicit drugs was more common among males than among females. Elements found to be associated with illicit drug use included high socio-economic group, low levels of achievement at school, high rates of failure at school, less involvement in volunteer social activities, transgressive behaviour, high scores in novelty seeking on the Tridimensional Personality Questionnaire and social coping impairment according to the Eysenck scale. Results of the present study suggest an increase in alcohol and illicit drug use among young people, in comparison with the results of previous studies, with the early onset of substance use in adolescents (persons aged 14-16). Many of the behavioural and psychometric changes associated with substance use do not correlate with the extent of exposure to alcohol and drugs. Such changes may be attributed in part to premorbid disorders and temperamental features. Prevention strategies need to focus on children and adolescent subtypes who show specific lifestyle, behavioural and psychological features.
Drug use most often begins in early adolescence. The sequence from tobacco use and alcohol consumption to marijuana use and then to the use of other drugs has been found in almost all long-term studies of drug use [1, 2]. The risk of moving on to heavy drugs has been found to be more than a hundred times higher for persons who have smoked marijuana at least once in their lives than for those who have not [3, 4]. The use of different illicit drugs and alcohol among students, based on the results of questionnaires completed by adolescents and young adults about their use of alcohol and cannabis, appears to be a widespread problem [5, 6]. Nevertheless, the differences in age and gender, the cultural variations, the types of schools attended and the different structures of the self-administered questionnaires make the results of those studies difficult to compare.
According to self-reported surveys of adolescent students in Nova Scotia, in Canada, carried out in 1991 and 1996, over one fifth (21.9 per cent) of the students reported having used alcohol, tobacco and cannabis in the 12 months prior to the 1996 survey .
In a study conducted in the United States of America and published in 1997, marijuana was the illicit drug used most often among medical students; it was reported to be used by 19-21 per cent of the students in the study .
On an undergraduate campus in the United Kingdom of Great Britain and Northern Ireland, the incidence of recreational use among college students of 3,4-methylenedimethoxymethamphetamine (MDMA), also known as ecstasy, was investigated more than 10 years ago  and again recently. Four years after the first study, the use of ecstasy had increased from 16 per cent to 24 per cent .
Concern about these developments is supported by the findings of a British survey on the lifestyle of medical students : reported use of cannabis and other illicit drugs had more than doubled in comparison with the data recorded in 1984 in the same area. In the 1994 survey, 49.2 per cent of the participants having used cannabis, 22 per cent had tried other illicit drugs and 39.3 per cent had anxiety ratings within the clinically significant rage; finally, in the 1998 update, cannabis had been used at least once or twice by more than half the males and by 40 per cent of the females, and 10 per cent of the participants reported regular (at least weekly) use . Consistent with those findings, a recent study found that rates of cannabis use increased from 15 per cent of the sample group at age 15 to 52.4 per cent of the same sample group at age 21 .
In Italy, few data are available about the proportion of young people using alcohol, cannabis and amphetamine derivatives. The 1995 European Schools Project on Alcohol and other Drugs Study  revealed that, in Italy, alcohol was consumed by a large proportion of students and that cannabis was used by nearly 20 per cent of the students.
An anonymous self-administered questionnaire on psychotropic drugs, completed by 3,212 secondary school students in Canada, showed that a proportion of personal problems were related to the use of psychotropic drugs (13.2 per cent among drug users, compared with 3.8 per cent among those who consumed alcohol only). Whether personal problems had been induced by the effects of drugs, or whether such problems already existed, thereby contributing to the vulnerability that opened the way for substance abuse, remains difficult to evaluate .
Aggressiveness, delinquency and poor social skills have been of prime interest in studying the psychological and behavioural traits as risk or predictive factors for alcohol and substance abuse [4, 14]. Drug and alcohol disorders generally follow rather than precede the onset of behavioural problems, suggesting that the former may be caused by the latter [15, 16]. Rates of cannabis use have been correlated with a history of violent behaviour  and antisocial personality disorder is considered by one author to be the personality profile most often associated with an individual's risk of alcoholism .
The relationships between adaptation to stress, coping strategies and substance abuse have become a popular focus of inquiry . Low academic achievement, disinhibited personality and susceptibility to peer pressure were independent predictors of self-reported drinking behaviour and experimental drinking in a laboratory setting  and of illicit drug use . Accordingly, early predictions of an alcohol use disorder in adulthood included early reports of underachievement in first grade by the child's teacher, some early problems in adaptive behaviours in school, dropping out of secondary school, whether the family set definite rules about school during adolescence and how often the adolescent worked on homework with his or her family .
The personality trait that suggests a strong tendency to seek novelties and low harm-avoidance seems to be another predictive factor for alcoholism and substance abuse among adolescents [22-24]. Such differences in both novelty-seeking and drug- seeking behaviour, while influenced to some degree by genetics, appear to be modifiable by early development experiences .
The literature supports the hypothesis that, given the same exposure to alcohol and illicit drugs, preferences for psychoactive drugs and the development of multiple use, poly-drug abuse and dependence could be influenced by environmental factors, lifestyle and psychological and behavioural features, all of which contribute to a young person's vulnerability .
If the hypothesis of the relationship between the consumption of alcohol and the use of drugs and psycho-behavioural factors could be confirmed, the early screening of risk factors [26-28] in school and the detection of more vulnerable subtypes among children and adolescents could become a priority of prevention programmes. In turn, primary prevention efforts could be enhanced, not only by avoiding the initial contact with alcohol and drugs per se, but by changing the conditions that affect lifestyle, behavioural and psychological risk factors. Secondary prevention efforts could focus on developing specific strategies, targeting adolescent subtypes having different degrees of vulnerability.
In order to better understand the extent of substance abuse, including the effect of coming into contact with gateway drugs, the drug preferences of Italian teenagers and the possible connection illicit drug use has with demographic, social, behavioural and psychological risk factors, a study was conducted to determine the rate of self-reported alcohol consumption and cannabis and ecstasy use among secondary-school students, some psychosocial features of the participants, their coping style and personality traits.
Material and methods
The study was based on a sample of 843 students aged 14-19 living in the province of Parma, Italy, and attending one of five secondary schools in the second half of 1998. The cohort was a stratified, randomized sample that included persons from all the areas of the province and the entire range of school grades and types of schools (focusing on a range of disciplines, including professional, technical and scientific fields and more traditional education). The mean age of the sample was 16.38 years (standard deviation: 1.69). Of the persons in the sample, 411 (48.75 per cent) were males and 432 (51.24 per cent) were females.
Before the study began, each person in the sample received detailed information about the survey and agreed to participate in it. The anonymity of the questionnaires was guaranteed.
Five subsamples were taken from the cohort. The first subsample comprised subjects who did not use alcohol or other illicit drugs; the second comprised those who admitted to having consumed (but not abused) alcohol without other illicit drugs; the third, those who reported having abused alcohol without other illicit drugs; the fourth, those who reported having used alcohol and cannabis; the fifth, those who reported having used alcohol, cannabis and ecstasy. In the sample were two ecstasy users who did not smoke cannabis or drink alcohol and three cannabis users who did not report their alcohol use; because they were so few in number, they were not included in the statistical analysis.
A questionnaire dealing with substance use (alcohol, cannabis and ecstasy) and another dealing with demographic data, the lifestyle and behavioural attitudes of the students as correlates of substance use, were distributed. Cloninger's Tridimensional Personality Questionnaire  and the Eysenck Questionnaire  were used to investigate aspects of personality.
The supply of illicit drugs, their general availability and their perceived use among peers were also tested.
Questionnaire on substance use
The questionnaire on substance use was designed as a modified version of the one developed by M?ller and Abnet  comprising 16 items that dealt with the use of both licit and illicit drugs.
The assessment of alcohol use was based on replies to a series of questions. The first question determined whether alcohol had ever been consumed by the subject. The second question concerned the frequency of alcohol consumption (the number of times alcohol had been consumed in the previous 30 days). The third question was presented as a detailed list of various alcoholic beverages where the number of alcoholic drinks consumed per day could be indicated. Another question evaluated the frequency with which spirits were consumed (daily or weekly, if at all). More than two drinks of wine or beer every day or more than three drinks of spirits every week constituted alcohol abuse.
Another item measured intoxication rates both in the previous 12 months and in the lifetime of the respondent.
As for cannabis use, the respondents were asked to indicate if they had ever smoked cannabis. To determine the frequency of current cannabis use, respondents were asked to indicate how many times they had used cannabis in the previous six months.
As for ecstasy use, the respondents were asked to indicate if they had ever taken ecstasy or similar drugs. To determine the frequency of current ecstasy use, the respondents were asked to indicate how many times they had used ecstasy in the previous six months.
In order to evaluate the use of illicit drugs and alcohol among classmates and friends, respondents were asked to estimate the percentage of their friends who consumed alcohol, smoked marijuana or used ecstasy.
The correlation between self-reported use of alcohol and illicit drugs and estimated use among friends supports the construct validity of the study. Regardless of whether the replies to the self-reported questionnaire were casual or incoherent, the rates of alcohol and drug use should correlate with the perception of use among peers, because of the affiliation of those experimenting with drugs to peer groups using illicit drugs. Thus, a lack of correlation between the self-reported rates of alcohol and drug use and the estimated rates of their use among peers reduces the significance of the results obtained by the study.
Questionnaire on behavioural, social and environmental factors
The questionnaire covered the following items concerning environmental and behavioural factors:
( a)Home area (urban (town) or rural (province): whether the subjects were resident in the town of Parma or in the rural part of the province);
( b)Socio-economic group (high, medium or low), related to parents' occupation: whether subjects' parents were professionals, employees, labourers or unemployed;
( c)School achievement (good or poor), related to self-reported mean school grades: good was rated as over 6, poor was rated as under 6;
( d)Hours of homework: whether the subjects were spending more or less than two hours per day on homework;
( e)School failure: whether the subject had failed exams and whether they had been refused admission to the next school level at least once;
( f)Involvement in volunteer social activities: whether the subjects were permanently involved in voluntary activities with social institutions, non-profit associations or non-governmental organizations;
( g)Transgressive behaviour: whether the subjects had been suspended from school for bad conduct or had frequently missed hours or days at school to avoid tests or evaluations; and whether the subjects had frequently committed driving violations;
( h)The setting conducive to substance use (alone, with friends, in the peer group);
( i)Substance use in discotheques.
The selection of items included in the questionnaire was based on research suggesting that environmental and social influences, school underachievement, incidence of dropping out of school and defiant and transgressive behaviour were conditions that increased the likelihood of students experimenting with illicit drugs. Bonding to social institutions and participating in voluntary activities were regarded as protective factors . The settings in which psychoactive substances were used (e.g. discotheques) were also investigated.
Social coping was assessed according to the Eysenck scale in the reduced version of 48 items, modified by Sanavio . The Eysenck questionnaire included the following four scales:
( a)Emotional stability and instability;
( b)Extroversion and introversion;
( c)Social coping and social coping impairment;
( d)Social desirability and undesirability.
In particular, the Eysenck questionnaire was used to investigate the third scale listed above, the social coping capacity, focusing on poor adaptation to stress, poor coping skills for social relationships and poor harm-avoidance behaviour. Those characteristics had been found to be related to an increased likelihood of substance abuse .
The assessment of novelty-seeking behaviour was made with Cloninger's Tridimensional Personality Questionnaire , which included scales measuring three different temperament-related dimensions: reward dependence, harm avoidance and novelty-seeking. Cloninger defines temperaments as stable dimensions of personality that seem to be influenced by genetic factors. The first temperamental trait identified by Cloninger corresponded to novelty-seeking, the proneness of individuals to involve themselves in new and unknown experiences, to seek sensations with high emotional impact and to be rewarded by risk-taking activities. A high novelty-seeking tendency, together with a low harm-avoidance tendency have been found to be linked to a higher likelihood of alcohol and substance abuse.
The statistical analysis included the chi-square test, multivariate analysis of variance, analysis of covariance, logistic regression analysis and the Pearson correlation between substance abuse and behavioural, temperament-related and psychological data.
The results of the study on alcohol use and abuse and cannabis and ecstasy use among secondary-school students are shown in table 1.
|Table 1. Alcohol, cannabis and ecstasy use among secondary-school students|
|Alcohol users||Alcohol abusers||Cannabis users||Ecstasy users|
The abstinent students (accounting for 23.49 per cent of the total) and the students who used alcohol (accounting for 76.51 per cent of the total) together represented 100 per cent of the sample (843 subjects).
Alcohol abusers, cannabis users and ecstasy users were included in the category of alcohol users. The first group, consisting of 198 subjects (71 males and 127 females), reported having abstained from using alcohol or illicit drugs. Of the 843 participants in the study, 645 (76.51 per cent) had consumed alcohol at least once, 324 (38.43 per cent) had abused alcohol, 229 (27.17 per cent) had smoked cannabis at least once in their lives and 47 (5.57 per cent) had used ecstasy.
As shown in table 2, of the younger students (aged 14-16), 73.39 per cent had consumed alcohol at least once in their lives; in addition, alcohol abuse was common among the adolescents in the study and the proportion of cannabis users (21.24 per cent) was not significantly lower among the adolescents than among the older students. Of the younger students, 3.64 per cent reported that they had used ecstasy at least once in their lives.
Table 2. Alcohol, cannabis and ecstasy use among
secondary-school students aged 14?16
|Alcohol users||Alcohol abusers||Cannabis users||Ecstasy users|
The age profiles of the students in the study who had abused alcohol and used cannabis and ecstasy are shown in figures I, II and III respectively.
Table 3 shows the gender distribution of the students who had used alcohol, cannabis or ecstasy.
Table 3 shows that the majority of abstinent students were female and that there were more male than female alcohol users and abusers and ecstasy users. No gender-related differences were observed among the cannabis users.
Table 3. Alcohol, cannabis and ecstasy use among
male and female secondary-school students
|Alcohol users||Alcohol abusers||Cannabis users||Ecstasy users|
The amount of alcohol consumed and the frequency of exposure to cannabis and ecstasy in the previous month are shown in table 4.
Table 4. Amount of alcohol consumed and frequency of exposure to cannabis
and ecstasy in the previous month
(drinks per month)
(exposures per month)
(exposures per month)
|66.45 ± 3.5
23.26 ± 2.1
45.95 ± 2.5
|13.92 ± 1.68
8.16 ± 1.02
13.20 ± 1.36
|11.10 ± 0.6
2.88 ± 0.3
8.13 ± 0.4
Males showed a significantly higher amount of alcohol consumption, cannabis use and ecstasy use.
A total of 435 (51.60 per cent) of the participants admitted that they had been drunk at least once in their lives; 223 (54.12 per cent) were males and 212 (49.18 per cent) were females. The frequency of an episode of drunkenness was not significantly different between males and females. A total of 46 (5.45 per cent) of the participants (8.25 per cent of the males and 2.78 per cent of the females) reported having been drunk 20 times or more in their lives.
All but two of the subjects reported that they had used ecstasy and had also smoked cannabis and abused alcohol.
The perceived use of alcohol and illicit drugs among peers (shown as a percentage of classmates or friends) correlated significantly with the self-reported use of alcohol and illicit drugs (measured in terms of the number of exposures in the previous month), supporting construct validity. The correlation between the self-reported use of alcohol and illicit drugs and their perceived use among peers demonstrates that the questionnaires were not answered casually, since those students who used more alcohol or illicit drugs also tended to be more involved in peer groups using drugs.
The perceived use of alcohol and illicit drugs among peers (the estimated percentage of classmates or friends using them) correlated significantly with the self-reported use of alcohol and drugs (measured in terms of the number of alcoholic drinks that were consumed or number of exposures to drugs in the previous month):
Proportion of peers
Proportion of peers
Proportion of peers
|Number of drinks or
number of exposures
to drugs in the
r = 0.370
r = 0.369
r = 0.340
Note: p = significance; r = correlation.
The participants were divided into the following five groups, according to the extent to which they used substances (see table 5):
( a)Group 1: persons who abstained from alcohol and illicit drugs;
( b)Group 2: alcohol users;
( c)Group 3: alcohol abusers;
( d)Group 4: alcohol abusers who smoked cannabis;
( e)Group 5: alcohol abusers who smoked cannabis and used ecstasy.
Alcohol abusers were included in groups 3, 4 and 5 but illicit drugs were used by those in groups 4 and 5 only.
Table 5. Groups of students characterized by substance used,
extent of use and gender
abstained from alcohol
and illicit drugs
|Alcohol users||Alcohol abusers||
The scores in psychometric areas (social coping and temperament-related aspects) obtained for the five groups are presented in tables 6 and 7.
Table 6. Scores obtained using Cloninger's
Tridimensional Personality Questionnaire
abstained from alcohol
and illicit drugs
|Alcohol users||Alcohol abusers||Cannabis users||Ecstasy users|
|16.27 ± 0.35
18.62 ± 0.39
18.51 ± 0.28
|16.54 ± 0.27
17.92 ± 0.30
18.60 ± 0.21
|17.81 ± 0.44*
16.43 ± 0.55*
18.98 ± 0.37*
|19.07 ± 0.38*
16.79 ± 0.41*
19.02 ± 0.27*
|19.17 ± 0.77*
17.06 ± 0.67*
17.53 ± 0.48*
Note: * = statistical significance p0.01.
|Table 7. Scores obtained using the Eysenck questionnaire|
abstained from alcohol
and illicit drugs
|Alcohol users||Alcohol abusers||Cannabis users||Ecstasy users|
|8.41 ± 0.21
6.36 ± 0.23
2.92 ± 0.14
6.86 ± 0.18
|8.73 ± 0.18
6.29 ± 0.19
3.16 ± 0.11
6.65 ± 0.14
|8.87 ± 0.21*
6.07 ± 0.36*
4.22 ± 0.21*
5.96 ± 0.25*
|9.42 ± 0.20*
6.54 ± 0.25*
4.38 ± 0.17*
5.42 ± 0.19*
|8.87 ± 0.40*
6.70 ± 0.43*
5.53 ± 0.34*
5.55 ± 0.39*
Note: * = statistical significance p0.01.
The percentage of subjects living in rural (provincial) areas was higher among the alcohol users and abusers who did not use illicit drugs (group 2 (70.5 per cent) and group 3 (70.96 per cent)) than in other groups.
The assessment of the students' socio-economic group showed no significant variation among those who abstained from alcohol and illicit drugs, alcohol users, alcohol abusers and cannabis smokers. In contrast, among ecstasy users (group 5), there were more persons from higher socio-economic groups.
The evaluation of temperament-related aspects using Cloninger's Tridimensional Personality Questionnaire revealed significantly higher mean scores in the area of novelty-seeking among alcohol abusers and among cannabis and ecstasy users than among abstinent subjects. The proneness to seek sensations of high emotional impact was found to be associated with alcohol abuse and cannabis and ecstasy use. The tendency to be novelty-seeking was progressively higher in groups 4, 5 and 6 compared with groups 1 and 2. Novelty-seeking, being an inherited psychological and behavioural condition, was not attributable to the effects of substance abuse, being regarded instead as a pre-existing condition.
Among alcohol abusers and cannabis users, significantly lower scores (compared with the scores of students who abstained from alcohol and illicit drugs) obtained using the Tridimensional Personality Questionnaire in the area of harm-avoidance were associated with high novelty-seeking. The unexpectedly moderate scores in the area of harm-avoidance among ecstasy users suggest the need for further study in order to better understand the relationship between temperament and addiction.
The evaluation of social coping impairment using the Eysenck questionnaire showed significantly higher mean scores for alcohol abusers, cannabis users and ecstasy users, compared with the scores of students who abstained from alcohol and illicit drugs and the scores of alcohol users. Subjects who had used illicit drugs showed more difficulties in coping with intimate relationships and had poor social skills. Results of the Eysenck questionnaire revealed poor adaptation to social relationships and showed that subjects who abused alcohol and used illicit drugs, particularly ecstasy, had more social problems.
Scores in the area of introversion obtained using the Eysenck questionnaire were higher for cannabis users than for students who abstained from alcohol and illicit drugs and for alcohol users.
It is likely that social coping impairment existed prior to substance abuse but this was not conclusively demonstrated by the present study.
The Pearson correlation did not reveal any significant relationship between the number of exposures to alcohol, cannabis and ecstasy and the scores obtained using Cloninger's Tridimensional Personality Questionnaire. Social coping impairment was directly correlated with both the number of drinks of spirits and wine. No other correlation was shown between Eysenck's psychometric measures and the extent of exposure to illicit drugs.
The results of the study reveal that the use and abuse of alcohol is widespread and that the use of cannabis and ecstasy is common among secondary-school students in the area of Parma, Italy. The use of psychoactive drugs and alcohol seems to take place extremely early in life, as shown by the proportion of 14-year-old users in the sample, suggesting that such activity may occur for some adolescents even earlier, at the age of 12 or 13.
Males who have used and abused alcohol and used ecstasy outnumber females. In contrast, no significant gender-related differences were observed among cannabis users. Exposure to psychoactive drugs and alcohol was more common among males.
Cannabis and ecstasy use, reported only by students who abused alcohol, indicates that alcohol abuse acts as a gateway for the use of illicit drugs.
The significant relationship between behavioural and psychometric findings and the amount of substance use taking place (including the use of multiple drugs, polydrug abuse and the number of exposures) indicates that better understanding and monitoring of secondary-school students' lifestyles, psychological traits, performance at school, transgressive behaviour and social coping ability could be used to enhance primary and secondary prevention strategies.
Alcohol use and abuse
The findings show that most of the students (76.51 per cent) consumed alcohol at least once before and a number (38.43 per cent) abused alcohol. Consistent with previous surveys in Italy and other European countries, there was a preponderance of male subjects among alcohol users and abusers [12, 32]. The amount of alcohol consumed in the previous month was also higher for male subjects.
Although it is difficult to compare the results of a local study with those of a national survey, the data indicate that there is an increase in the use of alcohol, consistent with the European Schools Project on Alcohol and other Drugs Study of 1995 . In 1995, the frequency of alcohol consumption (10 times or more in the previous 30 days) among students of the same age was 18 per cent for males and 5 per cent for females. In the present study, the proportion of subjects who reported having consumed alcohol 10 times or more in the previous 30 days was 24.55 per cent for males and 9.04 per cent for females.
The high proportion of subjects who consumed alcohol among the younger students (14-16 years old) suggests that contact with alcoholic beverages occurs in Italy at an early age and frequently, despite the fact that it is prohibited by law to sell alcohol to adolescents under 16 years of age. In Switzerland, a study on the early use of alcohol among children 10-17 years old revealed that 28 per cent of those children had used alcohol at least once in their lives .
Although the extent of alcohol abuse seems to have increased, the number of participants who said they had been drunk 20 times or more in their lives (8.25 per cent of males and 2.78 per cent of females) was less consistent. "Controlled abuse" of alcohol seems to prevail among the majority of the students in the study conducted in Italy, who showed a low rate of episodes of uncontrolled drinking ("binging") and drunkenness. Wine, the preferred alcoholic beverage in the sample studied, is associated with less frequent drunkenness and "binging" episodes. That confirms the view that wine, if consumed without other alcohol, is the beverage of moderation. The evidence indicates that those who drink beer, spirits, or those beverages and wine are not only heavier drinkers but are probably more rebellious and deviant .
The high prevalence of drunkenness among males compared with females suggests that the compulsive use of alcohol is associated with the male gender. A survey of university students in Scotland revealed that a slightly higher percentage of female students consumed alcohol compared with male students, but that the males consumed significantly more drinks per week .
The proportion of subjects who smoked cannabis but who did not abuse alcohol and the very small number of students who used ecstasy but not cannabis and alcohol suggest that the availability of illicit drugs and the likelihood of an addiction developing increase among alcohol abusers: the subjects who abstained from alcohol and illicit drugs and the subjects who used alcohol but did not abuse it showed the same low level of risk for cannabis and ecstasy use.
It is not possible to give a definitive explanation for the link between alcohol abuse and illicit drug use: on the one hand, cultural, psychological and psychobiological factors existing prior to the subject's abuse of substances could support the close relationship [23, 36-40]; on the other hand, self-medication (self-treatment) of alcohol-induced psychological and behavioural changes may be related to increased use of other psychoactive substances [41-44]. However, the results of the present study support efforts made to develop illicit drug prevention strategies that target alcohol abusers as a high-risk group. The results also support the development of prevention strategies that include both licit drugs (such as ethanol) and illicit drugs. Consistent with the results of the present study, early nicotine addiction and alcohol abuse were found in other studies to be predictive of other drug use in adults [45, 46].
The extent to which alcohol abuse occurred at an early age (at age 14) among the subjects in the present study should be regarded by public health authorities as a particularly alarming development because of the link between alcohol-correlated pathologies and the possible harm to psychological and behavioural development during adolescence.
More than 25 per cent of the students in the sample reported having used cannabis. In studies conducted in Italy in 1995 (self-reported unpublished data), 19-20 per cent of secondary-school students reported having used cannabis. No significant gender-related differences were found in the proportion of subjects who had smoked cannabis at least once in their lives. In contrast, the analysis of cannabis exposure demonstrated a significantly higher prevalence of cannabis use among male subjects, suggesting that cannabis is used by most females in low doses in a recreational context, and by males in high doses, indicating that males tended to be more dependent on cannabis.
Using cannabis at an early age, as did more than 20 per cent of the participants aged 14-16 years, may increase the risk of heroin and cocaine addiction in that age group, as demonstrated in a previous study .
The media and public opinion have contributed to a broad misunderstanding of the issue of the spread of cannabis use among students in Italy, resulting in an underestimation of the risks of cannabis use. Although the sample of cannabis users included students who had smoked at least once in their lives, previous studies of students' experimentation with cannabis have found that almost 40 per cent of the subjects who had tried cannabis became continued users of it .
The findings of the present study show that 5.57 per cent of the students in the study reported having used ecstasy. That implies widespread use of amphetamine derivatives among secondary-school students in Italy. Self-reported data in this field did not distinguish ecstasy from other amphetamine derivatives available in tablet form on the illicit market. Students described ecstasy as the stimulants sold in tablet form as MDMA. Both the proportion of MDMA users and the extent of MDMA exposure was greater among males than among females. The entactogen, energizing and psychedelic effects of ecstasy seemed to be more attractive to males than to females; the latter were found to take such tablets also for their effect on body weight [48-50]. The age of onset of ecstasy use was 16-17 years for most of the subjects. Some male subjects, however, had experimented with ecstasy at the age of 14.
Other studies conducted in the north of Italy in 1998 showed higher numbers of ecstasy users: 7.00 per cent in Padua and 8.7 per cent in Milan. Those data cannot be easily compared with the present findings, however, because the selection of participants was different .
Psychological and behavioural features of student subtypes
Previous studies comparing students in rural and in urban areas found that the former showed a higher prevalence for alcohol use (particularly excessive use) [52, 53]. The present study showed that alcohol use and abuse were more consistent among students in rural areas than among students living in urban areas.
Conflicting data have been reported with regard to the relationship between habits involving alcohol use, substance abuse and socio-economic status. A Swedish survey suggested that special attention in the form of work to prevent alcohol abuse should be given to young people in lower socio-economic groups . A positive relationship between income level and high alcohol intake was shown in other studies . The results of the present study do not show any relationship between alcohol use (and abuse) or cannabis use and the socio-economic status of the family. High socio-economic status was significantly more prevalent among the ecstasy users than among the other groups, suggesting that amphetamine derivatives were the drug of choice of a segment of society having more stable social integration, money available and preferences for certain stimulants.
Underachievement and failure at school have been frequently associated with alcohol and substance abuse. Other studies have found that drug use is significantly higher in young people who are school dropouts than in those who stay in school  and that a student's level of academic performance contributes to the likelihood of him or her using gateway drugs .
The possible causal relationship between failure at school and substance abuse is still unclear: on the one hand, the effects of cannabis and alcohol include cognitive deficit and memory dysfunction that could impair performance at school [58, 59]; on the other hand, students with conditions associated with failure at school that exist prior to substance abuse, such as low self-esteem, may be more at risk of taking drugs [4, 60, 61]. The data show a close association between difficulties at school, few homework hours and low school achievement among illicit drug users; ecstasy users, in particular, reported failure at school.
There is evidence of the protective role of involvement in social institutions, local community groups and volunteer associations . In the present study, about 10 per cent of the students who abstained from alcohol and illicit drugs were involved in volunteer social activities; significantly fewer students that reported alcohol abuse and cannabis and ecstasy use were involved in such activities.
Unexpectedly, about 40 per cent of the students using marijuana and about 60 per cent of those using tablets reported that they used those substances when they were alone (that is, not together with their peers). Such a pattern of substance abuse could indicate a strategy of self-medication [43, 62] associated with social exposure anxiety, rather than a ritualized social behaviour. Discotheques and rave parties appear to be the main settings in which ecstasy was used, according to the self-reported data. Such settings are probably preferred subconsciously, because of the effect of fast music, which has been found to be able to influence brain monoamine release .
A variety of studies investigating risk factors for alcohol abuse, childhood hyperactivity and antisocial personality traits showed that deviant behaviour in childhood and early adolescence was linked to alcohol abuse . Earlier studies showed that diagnoses of current conduct disorder were reported in 82.1 per cent of cannabis users  and that ecstasy users exhibited elevated impulsiveness in both self-reported data and behavioural studies . Similarly, the present data demonstrated a low mean rate of transgressive behaviour among students who abstained from alcohol and illicit drugs and among alcohol users, a high rate among alcohol abusers and illicit drug users and a particularly high rate among ecstasy users, consistent with the results of previous studies that suggested aggressiveness was a risk factor existing prior to substance abuse .
It has been suggested that a close link exists between sensation-seeking and drug use . The different dimensions of sensation-seeking were identified as strong predictors of future drug use: "disinhibition" was a common factor in drug use for both sexes. In males, a response of "thrill- and adventure-seeking" indicated moderate alcohol consumption and a response of "experience-seeking" indicated cannabis use . In addition, a novelty-seeking temperament has been reported to be a predictive factor for substance abuse in other studies [22-24]. Similarly, for participants in the present study who used illicit drugs and abused alcohol, higher mean scores in the area of novelty-seeking were obtained using Cloninger's Tridimensional Personality Questionnaire.
Previous studies showed that cannabis and ecstasy users tend to exhibit depressive traits [70, 71] and that alcohol abusers tend to be less extroverted . Such findings may be connected with the significant impairment in social coping, according to the Eysenck scale, that was shown among participants of the present study who used illicit drugs and abused alcohol.
The lack of statistical correlation between psychometric changes and the reported extent of exposure to alcohol and drugs, apart from the relationship between social coping measures and the consumption of alcohol, suggests that underlying the effects of substance abuse, including psychiatric disorders, high novelty-seeking, low harm-avoidance, social coping deficit and social undesirability, may be a complex premorbid disorder associated with substance abuse but not completely due to substance abuse [71, 73-75].
In conclusion, the present study suggests that high numbers of adolescents are exposed to alcohol and illicit drugs while in secondary school, that the risk of cannabis and ecstasy use is associated with alcohol abuse and is rarely evident in subjects who abstain from alcohol. Transgressive behaviour and lower school achievement, a proneness to seek new and intense emotional experiences and to exhibit risk-taking behaviour, poor social skills and inconsistency in coping with interpersonal relationships have been found to correlate with a tendency to experiment with drugs and abuse alcohol.
The present findings, although preliminary and obtained from a limited sample, indicate the need for specific early intervention that targets children and adolescents whose performance at school is poor, whose behaviour is disruptive, whose temperament tends to be novelty-seeking and who are maladjusted socially. The aim is to prevent substance abuse and the use of gateway drugs among young adults. In addition, the different psycho-behavioural features of student subtypes, characterized by an increase in substance use, suggest that secondary prevention strategies can be enhanced if the appropriate methodologies are used.
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*The authors gratefully acknowledge the contributions made to the present study by the secondary schools of Parma, Luigi Vincelli, Provveditore agli Studi di Parma and Maura Gatto, Chief of the Health Education Office of Parma.